The influence of acute lifestyle changes on NAFLD evolution in a multicentre cohort: a matter of body composition

Background Unhealthy lifestyles represent a key element fueling Non-alcoholic fatty liver disease (NAFLD) onset and worsening. We aimed to evaluate the effects of forced acute lifestyle changes on NAFLD evolution. Methods 187 NAFLD patients were followed two years pre- and two years during the lockdown social restrictions in three Italian medical centers. For each patient, biochemical, clinical, non-invasive liver fibrosis, nutritional, and body composition data were collected. Results An increase in fats and carbohydrate intake associated with impaired weekly physical activity during the lockdown was demonstrated as well as an increase in body mass index and waist-hip-ratio (p < 0.0001 for all). Total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, glucose, insulin, homeostatic model assessment for insulin resistance, and transaminases worsened during the lockdown (glucose: p = 0.0007; p < 0.0001 for the others). Moreover, NAFLD fibrosis score, liver stiffness, and controlled attenuation parameter were also impaired during the same period (p < 0.0001 for all). The bioelectrical impedance analysis (BIA) evidenced an increase of fat mass (FM), and a reduction of free fat mass (FFM) and body cell mass (BCM) (p < 0.0001 for all). The lockdown overall hepatocellular carcinoma (HCC) and Milan-out HCC occurrence revealed Hazard Ratio (HR): 2.398, 95% Confidence Interval (CI):1.16–5, p = 0.02, and HR:5.931, CI:2–17.6, p = 0.008 respectively. A liver disease stage and comorbidities independent association between both the assessed outcomes and body composition analysis in terms of mean values and variation (T1–T2 Δ) was demonstrated. Conclusions The acute lifestyle changes impacted NAFLD evolution via body composition modifications negatively influencing the HCC occurrence.


Background/rationale
Explain the scientific background and rationale for the investigation being reported 4 Objectives State specific objectives, including any prespecified hypotheses 4-5

Study design
Present key elements of study design early in the paper 5-6 Setting Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection  Supplementary File 2. Food intake and Physical exercise assessment: explanation of the used tools.

Food Intake assessment
We recorded, by using a diet diary, the food intake for a complete week, including working days and weekends by using the software WinFood, Medimatica s.r.l.
Based on the quantities and qualities of food consumed, the program estimates the percentage of macronutrients and micronutrients in each food and elaborates the daily energy intake in terms of Kcal per day referring to the caloric amount as specifically related to carbohydrates, fats, and proteins dietary proportions.

Physical exercise assessment
Medical validated questionnaire and relative items assessing physical exercise practicing in enrolled patients.

Questions/Items Answer
Are you doing or have you ever done (in the last 2 years) sport in a continuative and regular way?
Cohort study-Give the eligibility criteria, and the sources and methods of selection of participants.Describe methods of follow-up Case-control study-Give the eligibility criteria, and the sources and methods of case ascertainment and control selection.Give the rationale for the choice of cases and controls Cross-sectional study-Give the eligibility criteria, and the sources and methods of selection of participants 6-7 (b) Cohort study-For matched studies, give matching criteria and number of exposed and unexposed Case-control study-For matched studies, give matching criteria and the number of controls per case VariablesClearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers.
your daily physical activity in the last 6 months?NO YES If yes, has it enhanced or worsened?Enhanced Worsened How many hours per week do you usually spend for physical exercise?considered on active physical exercise if he/she has done sports in the last 2 years, this practice has not worsened in the last 6 months by spending at least 150 minutes per week in physical activity.Supplementary File 3. Dietary composition modifications (A) Dietary composition modifications (overall) *Carbohydrates, **fats, and ***proteins proportions comparison by using ANOVA and Tukey post hoc analysis between baseline and end of the study evaluations, p<0.0001.The intermediate column (T1) indicates the January 2020 time-point assessment.(B) Dietary composition modifications (fat types) x Polyunsaturated fats, xx Monounsaturated fats, and xxx Polyunsaturated fats' proportions comparison by using ANOVA and Tukey post hoc analysis between baseline and end of the study evaluations.X: not statistically significantly different.The intermediate column (T1) indicates the January 2020 time-point assessment.(C) Dietary composition modifications (carbohydrate types) x Polysaccharides, xx Disaccharides, and xxx Monosaccharides' proportions comparison by using ANOVA and Tukey post hoc analysis between baseline and end of the study evaluations.X: not statistically significantly different.The intermediate column (T1) indicates the January 2020 time-point assessment.

Assessment of LSM, CAP, and NFS of the study population among the three-time points evaluations by age, sex, BMI, T2D, and SarsCoV2.
The sensitive analysis for main outcomes stratified by age, sex, obesity, diabetes, and Sars-CoV-2.